PROJECT SUMMARY Nearly 70% of US adults are overweight or obese, and the consequences can include increased risk for several types of cancer, diabetes, and cardiovascular disease. Compared to their urban counterparts, rural residents tend to have higher rates of cancer, obesity, physical inactivity, and poor diet. Rural residents also have higher rates of poverty and lower rates of health insurance, and face unique challenges accessing healthy foods, and/or physical activity opportunities, which contribute to these rural health disparities. Civic engagement for built environment change (CEBEC) integrates resident-led community assessments with environmental change initiatives aiming at improving population health. In several pilot studies, engaging and empowering residents to identify solutions to improve community health have demonstrated successful implementation. Evidence demonstrating positive change in behaviors and health outcomes using the CEBEC approach are limited in scope and rigor but show notable and encouraging outcomes (e.g. increased physical activity). This study proposes to evaluate a CEBEC intervention, the multilevel Change Club (CC) project, which would be implemented in eight rural locations. The objective of the CC is to reduce rural risk factors for obesity, cancer, and other chronic diseases through CEBEC physical activity and healthy eating projects. The CC provides a menu of effective interventions; step-wise planning strategy; behavior change strategies and goal setting; assessment and engagement tools; and ongoing support via conference calls, webinars, and discussion boards to rural resident CCs, which typically include about 12-16 residents. For Aim 1, we will evaluate individual-level health and behavioral outcomes in eight rural towns. We will measure outcomes in CC members, local social network members (SNM) of CC members, and a sample of town residents recruited through mass mailings and community events. The primary outcome is Simple 7 composite cardiovascular risk score, which includes blood pressure, glucose and cholesterol, BMI, diet, smoking, and physical activity; additional outcomes are knowledge, attitudes, beliefs, and self-efficacy related to healthy eating and exercise, including use of community resources for healthy eating, physical activity, and health care; and environmental factors. Objective measures, including BMI, biochemical measures, accelerometry, dermal carotenoids, and blood pressure, will be collected with CC members and a sample of SNM and town residents. Aim 2 includes a mixed methods process evaluation examining unintended consequences; implementation barriers and facilitators, including costs; and the effect of community/built environment/policy, social/collective, and individual-level factors on intervention-specific outcomes. We will compare costs across sites and explore cost- effectiveness of CC interventions relative to change in Simple 7 score. This project is an innovative opportunity to evaluate multilevel rural CEBEC interventions focused on chronic disease risk factor behaviors. Outcome and process data will provide critical insight into the viability of CEBEC interventions for future dissemination.